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Clinical coding and data quality in oculoplastic procedures.

Valerie Juniat1, Sarju Athwal2,3, Mona Khandwala2

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Accurate coding of oculoplastic procedures is crucial for hospital reimbursement. An audit revealed significant coding errors, but a targeted intervention improved accuracy to 85.7%, highlighting the financial benefits of precise clinical coding.

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Area of Science:

  • Ophthalmology
  • Health Economics
  • Medical Administration

Background:

  • Hospitals in England receive reimbursement based on national tariffs set by NHS England.
  • Tariff payments are determined by the coded activity for each patient's hospital visit.
  • No national standards exist for coding accuracy in oculoplastics.

Purpose of the Study:

  • To audit the accuracy of coding for oculoplastic procedures performed in theatres.
  • To assess the financial implications of coding discrepancies in oculoplastics.

Main Methods:

  • A prospective audit of consecutive oculoplastic procedures was conducted over 6 weeks.
  • A coding proforma was developed and used for a subsequent re-audit.

Main Results:

  • Initial coding accuracy was low: 30.7% correct, 12.9% incomplete, and 56.5% incorrect.
  • A significant portion of incorrect codes (54.3%) were for non-oculoplastic procedures.
  • Following intervention, re-audit showed improved coding accuracy to 85.7%.

Conclusions:

  • Clinical coding is complex and prone to errors, impacting hospital finances.
  • Collaboration with coding teams and the use of coding proformas can significantly improve accuracy.
  • Accurate coding is vital for financial health of hospital trusts and could yield savings if implemented across specialties.